Key Facts

Laryngitis is inflammation of the larynx affecting the vocal cords and surrounding structures. Acute laryngitis is extremely common, usually viral, and self-limiting. Chronic laryngitis (hoarseness >3 weeks) warrants investigation to exclude underlying pathology including malignancy.

Epidemiology

• Acute laryngitis: extremely common; often accompanies URTI
• Affects all age groups
• More common in winter months
• Professional voice users (teachers, singers, call centre workers) are more susceptible

Aetiology

• Acute: viral (most common — rhinovirus, influenza, parainfluenza, adenovirus), bacterial superinfection (rare), voice abuse
• Chronic: smoking (most important risk factor for malignancy), gastro-oesophageal/laryngopharyngeal reflux, chronic voice abuse/misuse, inhaled corticosteroids (candidiasis), allergic laryngitis, granulomatous disease (sarcoidosis, TB, GPA), fungal laryngitis (immunocompromised)

Pathophysiology

• Viral infection causes mucosal oedema and inflammation of the vocal cords
• Swollen, inflamed cords vibrate irregularly, producing hoarse voice
• Chronic irritation (smoke, acid, voice abuse) causes epithelial changes: oedema, keratosis, leucoplakia, dysplasia
• Progression from chronic irritation → dysplasia → carcinoma in situ → invasive carcinoma is the concern with chronic laryngitis

Acute Laryngitis

• Hoarseness or voice loss (aphonia)
• Sore throat
• Dry, irritating cough
• Voice fatigue
• Associated URTI symptoms (coryza, malaise)
• Self-limiting within 7-10 days

Chronic Laryngitis

• Persistent hoarseness (>3 weeks)
• Voice change (deeper, rougher)
• Throat clearing habit
• Globus sensation (feeling of lump in throat)
• Chronic cough

Red Flags

• Hoarseness >3 weeks (exclude malignancy — NICE NG12)
• Stridor (airway obstruction)
• Dysphagia or odynophagia with hoarseness
• Haemoptysis
• Weight loss
• Smoker/ex-smoker with persistent hoarseness (high malignancy risk)
• Unilateral vocal cord palsy on laryngoscopy (recurrent laryngeal nerve — think lung/thyroid cancer, aortic aneurysm)

Bedside

• Voice assessment (perceptual — GRBAS scale: Grade, Roughness, Breathiness, Asthenia, Strain)
• Examination of neck (lymphadenopathy, thyroid)

Bloods

• Not routinely required for acute laryngitis
• TFTs if hypothyroidism suspected
• ACE level if sarcoidosis suspected

Imaging

• Not required for acute self-limiting laryngitis
• CT neck/chest: if malignancy suspected or vocal cord palsy identified
• MRI: for soft tissue detail of laryngeal lesions

Special Tests

• Fibreoptic nasendoscopy (FNL): essential for hoarseness >3 weeks
  • Visualises vocal cords, assesses mobility, identifies lesions
• Direct laryngoscopy and biopsy: under GA for suspicious lesions
• Stroboscopy: detailed assessment of vocal cord vibration
• 24-hour pH monitoring / impedance: for laryngopharyngeal reflux
• Speech and language therapy assessment: for functional voice disorders

Non-pharmacological

• Voice rest (reduce voice use, not complete silence)
• Adequate hydration
• Steam inhalation
• Humidification of environment
• Avoid irritants (smoking, alcohol, dusty environments)
• Speech and language therapy: for chronic voice disorders, vocal cord nodules, functional dysphonia

Pharmacological

• Acute viral laryngitis: NO antibiotics (self-limiting)
• Simple analgesia (paracetamol, ibuprofen)
• Laryngopharyngeal reflux: PPI trial (omeprazole 20mg BD for 2-3 months)
• Inhaled corticosteroid-related laryngitis/candidiasis: mouth rinse after inhaler use, consider spacer, dose reduction
• Fungal laryngitis: oral fluconazole 50mg OD for 2 weeks

Surgical

• Microlaryngoscopy and excision/biopsy: for vocal cord polyps, nodules (refractory to speech therapy), suspicious lesions
• Laser treatment: for papillomatosis, leucoplakia
• Laryngeal framework surgery: for vocal cord palsy (medialization thyroplasty)
• Injection laryngoplasty: hyaluronic acid injection for vocal cord palsy (temporary)

Referral Criteria

• 2-week wait ENT referral (NICE NG12): hoarseness >3 weeks, particularly smoker/ex-smoker >45 years, or neck lump >3 weeks
• Routine ENT referral: recurrent laryngitis, chronic voice change, vocal cord nodules
• Speech and language therapy: for voice rehabilitation
• Emergency: stridor, airway compromise

• Acute viral laryngitis: resolves within 7-10 days in almost all cases
• Vocal cord nodules: >80% resolve with speech therapy alone (surgery rarely needed)
• Vocal cord polyps: may require surgical excision if not responding to voice therapy
• Laryngopharyngeal reflux: often improves with 2-3 months of PPI + lifestyle modification
• Reinke oedema: improvement with smoking cessation; surgical debulking if persistent
• Laryngeal carcinoma: 5-year survival for early (T1) glottic carcinoma: >90% with radiotherapy

GRBAS Voice Assessment Scale

Causes of Vocal Cord Palsy